Family clinic out-patient follow-up
Wt
Ht
SA
OFC
BP
(Sticker)
Clinical review
Age:
Date:
Consultant________
Diagnosis knowledge
kg centile___
Full:
cm centile____
Partial:
m2
None:
cm centile____
HR
Urinalysis
Blood:
Protein:
Glucose:
Leukocytes:
Current medication
Drug
Susp/tabs
Dose(in mg)
Freq
Adherence
Any missed doses in last 7days
Dose per
kg / m2
Any missed doses in last month
Body Shape
Are you happy with the shape of your body?
Do you think any part of you is too fat or too thin?
Today’s
changes
Side effects of
treatment
Examination
Pubertal stage
Signs of Fat redistribution
Increased central fat
Thin limbs, buttocks
Thin face
yes / no
yes / no
yes / no
Investigations performed today ()
FBC + diff
T-cell subsets
U+Es/LFTs
Amylase
Vitamin D/PTH
Other Ix (specify)
Cholesterol/TGs
Lactate/bicarbonate
Viral load (Roche/Chiron)
CXR
Diagnostic PCR
HIV Serology
Other virology (specify)
New Referrals ()
Dentist
Ophthalmology
Multi-disciplinary Review
Signature: __________________
Plan
Next appointment:
Growth chart?
Flow chart?
Where__________
When_________
Letter written?
Signature: __________________